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HINTS 



liditat jpatnin^, 



Bt GEO. EMMET HALL, M. D. 



PRESENTED 



lahnemann 



m insurance 



4 



mttpmg, 



CLEVELAND, 0. 



-*« 



CLEVELAND: 

PBINTED AT THE OFFICE OF THE HAHNEMANNIAN. 
1871, 



*tf 






Entered according to Act of Congress, in the year of our Lord 

1871, by the 

HAHNEMANN LIFE INSURANCE COMPANY, 

Of Cleveland, Ohio, in the Office of the Librarian of Congress. 

at Washington, D. C. 



THESE PAGES ARE RESPECTFULLY DEDICATED 
TO 

PROF. H. P. GATCHELL, M. D., 

OF OAK GROYE SANITARIUM, KENOSHA, WIS., 

AS 

A MARS OF ESTEEM FOR HIS PRIVATE CHARACTER, DISTINGUISHED 

TALENTS AND HIGH PROFESSIONAL STANDING. 



OPFICEBS 



mlmemann Sife jjttsuraiue $om$nnv. 



H. M. CHAPIN, Pres't. 

L. D. COETRIGHT, JAMES WADE, Jt, 

VICE PRESIDENTS. 

J. F. CRANK, Secretary. 

GEO. EMMET HALL, M. D., Med. Ex'r. 

J. K. STOCEWELL, Actuary. 



HOME OFFICE, 



CASE BUILDING, 



CLEVELAND, O. 



KOTE. 

aim of this little pamphlet is to exhibit some of 
$f§f£? the more prominent features relating to Examina- 
tions for Life Insurance, and to suggest the necessity for 
extreme care on the part of the physician in recommending 
risks. 

No attempt at instruction in physical, or other methods 
of diagnosis, is made, it being presumed that no one unless 
fully competent would assume the responsibilities of an 
Examiner. 



EXAMINEES AND AGENTS. 



t^HILE the relations of the Medical Examiner with 
IS^Dv® tne Agent of the Company should, if possible, be of 
a friendly character, and the labors of both should be for the 
interests of the Company, no personal friendship or other 
motive will induce the conscientious Examiner to recommend 
any undesirable risk, no matter how much time and labor 
may have been expended by the Agent in securing the same. 
And he will bear in mind that he is a sentinel, selected to 
prevent the Company from becoming a hospital for the recep- 
tion of invalids, be they strangers or friends, and that so 
long as he acts for the Company it will hold him strictly 
accountable for any risks accepted upon his recommendation 
which may eventually exhibit evident carelessness in the 
examination. The Company also expects the Examiner to 
consider its interests paramount to those of any of its 
Agents, and if at any time any facts should exist with refer- 
ence to an examination, which in the opinion of the Exam- 
iner it would be best not to note on the Application, he 
should at once write to the Medical Examiner at the Home 
Office, giving full particulars of the case, which letter will 
be held as strictly confidential. 

Examiners are earnestly invited to correspond with the 
Home Office in relation to any case coming before them for 
examination, which, in their opinion, may not be such as the 
Company could safely accept, and correspondence upon any 
subject that in any manner interests the Company will be 
acceptable and fully appreciated at all times* 



8 HINTS tO MEDICAL EXAMINEES. 

APPLICANTS. 

The Examiner will not fail to remember that the class of 
diseases with which he will most frequently meet in appli- 
cants for insurance will be of the chronic variety. Seldom 
will he be called upon to examine for insurance any individ- 
ual while laboring under an acute malady. Those presenting 
themselves for examination will, if diseased, of course make 
the most favorable representation of their case possible, and 
will conceal and disguise any facts regarding their health 
which would tend to condemn them for insurance. 

On the other hand, a patient applying to a physician for 
medical aid, is very anxious to inform his medical adviser of 
all his aches, pains and other symptoms, confiding to him 
every little particular that has the least bearing upon his 
case. In this he resembles the conscript who parades all his 
aches and pains before the army surgeon, that he may 
thereby escape military service. The motives of the three 
it will be observed, are quite different. Regarding those 
who occasionally present themselves for insurance without 
/ having been solicited by an agent of the company, suspicion 
may be very justly excited, for it is seldom that an individual 
applies for insurance upon his life, unless solicited, although 
it is common to apply for insurance upon property, and, 
where such cases occur, unusual care on the part of the 
Examiner should be exercised. Persons who are aware of 
the presence of some disease which will sooner or later prove 
fatal, or which is gradually undermining their health, and 
conscious that no provision has been made for those depend- 
ent upon them in the event of death, hasten to perform the 
neglected duty. 



DUTIES OF THE EXAMINEE. 



^fj[X examining applicants for Life Insurance it devolves 
(gjg upon the physician, in his official capacity, to detect if 
disease actually exists, or if there be any tendency or predisposition 
to any disease which may, in the future, make the risk a hazardous 
one, for not only must the physician be able to testify to a sound 
and healthy condition of the candidate for insurance, at the time of 
the examination, but he should also be fully satisfied that the 
applicant stands a fair chance of reachiug the age necessary to 
make the Company secure. As but one class of risks is desired 
by this Company, a person to be insurable for a shorter term 
should be good for life. The success of any life insurance 
company rests, to a very great extent, with its Examiners, 
and too close scrutiny and investigation can not be practiced 
by the physician. The object to be attained is of course to 
establish whether the applicant will reach his expectancy of 
life. What that expectancy is can be readily seen by refer- 
ence to the annexed table. 

To establish certainly that in any given case the individual 
would reach the age specified in the table would be simply 
impossible, yet there is every reason to conclude that persons 
who have inherited good constitutions, who live temperately, 
in salubrious regions, and who are employed in occupations 
not calculated to impair the general health, will attain to a 
greater longevity than under other and less favorable cir- 



10 



HINTS TO MEDICAL EXAMINERS. 



cumstances. Very large or tall men do not possess the same 
endurance as men of medium stature, which fact was fully 
demonstrated during the war with Mexico and in the great 
rebellion. 

EXPECTATION OF LIFE. 

The following is according to the Carlisle Tables of Mortality, 





Expectation 




Expectation 


1 


Expectation 


Age. 


in vears and 


Age. 


in years and 


Age. 


in years and 




lOOths. 




I lOOths. 




lOOths. 


14 


45.75 


43 


25.71 


72 


8.16 


15 


45.00 


44 


25.09 


73 


7.72 


16 


44.27 


45 


24.46 


74 


7.33 


17 


43.57 


46 


23.82 


75 


7.01 


18 


42.87 


47 


23.17 


76 


6.69 


19 


42.17 


48 


22.51 


77 


6.40 


20 


41.46 


49 


21.81 


78 


6.12 


21 


40.75 


50 


21.11 


79 


5.80 


22 


40.04 


51 


20.39 


80 


5.51 


23 


39.31 


52 


19.68 


81 


5.21 


24 


38.59 


53 


18.97 


82 


4.93 


25 


37.86 


54 


18.28 


83 


4.65 


26 


37.14 


55 


17.58 


84 


4.39 


27 


36.41 


56 


16.89 


85 


4.12 


28 


35.69 


57 


16.21 


86 


3.90 


29 


35.00 


58 


15.55 


87 


3.71 


30 


34.34 


59 


14.92 


88 


3.59 


31 


33.68 


60 


14.34 


89 


3.47 


32 


33.03 


61 


13.82 


90 


3.28 


33 


32.36 


62 


13.31 


91 


3.26 


34 


31.68 


63 


12.81 


92 


3.37 


35 


31.00 


64 


12.30 


93 


3.48 


36 


30.32 


65 


11.79 


94 


3.53 


37 


29.64 


66 


11.27 


95 


3.52 


38 


28.96 l 


67 


10.75 1 


96 


3.46 


39 


28.28 


68 


10.23 


97 


3.28 


40 


27.61 


69 


9.70 


98 


3.07 


41 


26.97 


70 


9.18 


99 


2.77 


42 


26.34 | 


71 


8.65 


100 


2.28 



HINTS TO MEDICAL EXAMINERS. 



11 



; The following Table, taken from the New York Underwriter^ 
gives the ratio of deaths, in England, from each cause, to 
1,000,000 deaths from all causes. 



Consumption, 118,003 

Bronchitis, 86,554 

Atrophy and Debility, .... 69,284 

Old Age, 61,414 

Convulsions, 56,294 

Heart Disease, 46,499 

Pneumonia, 45,275 

Diarrhoea, 42,559 

Typhus, 36,150 

Scarlatina, 26,370 

Pertusis, 25,454 

Paralysis, 23,175 

Apoplexy, 22,309 

Premature Birth, 19,272 

Cancer, 18,320 

Dropsy, 15,112 

Hydrocephalus, 15,095 

Tabes Mesenteric^, 14,754 

Fracture and Contusion, . . 14,141 

Rubeola, 14,124 

Brain disease 12,158 

Liver disease 11,859 

Lung disease, not Phthisis, 10,278 

Croup, 9,405 

Cephalitis, 9,047 

Asthma, 8,035 

Sud'n death, cause unk'wn 7,516 

Disease of Stomach, 6.320 

Scrofula, 6/299 

Kidney disease, 6,260 

Enteritis, 6,127 

Drowning, (accident,) 5,737 

Burns & Scalds, (accid't,) . 5,574 

Diphtheria, 5,574 

Small Pox, 5,388 



ChildBirth, 5,029 

Epilepsy, 4,957 

Rheumatism, 4,837 

Nephria, 4,723 

Syphilis, 3,641 

Disease of Joints, 3,584 

Peritonitis, 3,368 

Jaundice, 3,201 

Erysipelas, 3,109 

Suffocation, (accidents,) . . . 2,899 

Mortification, 2,849 

Hepatitis, 2,828 

Laryngitis, 2,755 

Ileus, 2.528 

Aphthae, 2,493 

Accident, not specified. 2.393 

Uterine disease, 2,291 

Metria, 2,285 

Dysentery, 2.062 

Ulceration of Intestines, ... 1,990 

Hernia, 1.987 

Cholera, 1,977 

Pleurisy, 1,854 

Gastritis, 1,599 

Ascites, 1,552 

Diabetes, 1,458 

Insanity,. 1,372 

Influenza, 1,301 

Pericarditis, 1,269 

Malformations, 1.081 

Aneurism, 1.078 

Hanging, (suicide,) 1,046 

Cyanosis, 1,031 

Purpura and Scurvy, 1.010 

Ulcer, 950 



12 HINTS TO MEDICAL EXAMINERS. 

Nephritis, 948 Noma, 373 

Phlegmon, 922 Worms, 369 

Murder and Manslaughter, . . 840 Suicide, (not specified,) 300 

Spina Bifida, 832 Poison, (suicide,) 289 

Cystitis, 817 Gunshot, (accident,) 266 

Gout, 808 Ague, Congestive, 259 

Intemperance, 802 Privation, 234 

Delirium Tremens, 791 Ischuria, 227 

Skin Disease,not specified, . . . 776 Zymotic, (not specified,) 225 

Violent Deaths, not specified, 645 Cut or Stab, (accident,) 221 

Introsusception. 635 Fistulse, 214 

Poison, (accident,) 602 Spleen, disease of,. 199 

Stricture of Intestines, 596 Remittent Fever, 184 

Cut or Stab, (suicide,) 575 Arthritis, 161 

Ovarian Dropsy, 530 Gun Shot, (suicide.) 122 

Carbuncle. 504 Chorea, 107 

Drowning, (suicide,) 489 Pancreas, disease of, 39 

Stone, 431 Hanging, (execution,) 24 

Quinsy, 431 Hydrophobia, 21 

Stricture of Urethra, 422 Glanders, 9 

OCCUPATION. 

Every medical man is conversant with the fact that certain 
occupations are far more favorable to the attainment of a 
long life than others. Employments that are carried on in 
the open air, or at least where a large portion of the labor is 
performed out of doors, are of the class most conducive to 
good health and longevity. Quite a number of occupations 
are extremely pernicious to health, so much so that persons 
following them are positively unfit as insurance risks. 
Among the class referred to are: Glass blowers, miners, 
quartz-mill operators, workers in chemical manufactories, 
white lead and match factories, burr stone and grind stone 
works, brakemen on freight trains, also those employed in 
powder mills, or as pyrotechnists, (on account of extreme 



HINTS TO MEDICAL EXAMINERS. 13 

hazard,) marble and stone cutters and carvers, plumbers 
and painters using and handling lead and turpentine, are 
poor risks, inhalations of stone and marble dust inducing 
lung disease, and the handling of lead and inhalations of lead 
and turpentine causing paralysis and colica pictonum. 
Machinists and mechanics generally are good risks, but the 
professional ranks afford the best. Clergymen, teachers, law- 
yers, artists, public speakers, professional lecturers and 
physicians, more particularly those who practice in cities, 
and farmers or agriculturists generally, are the best class 
from which to select. 

It is a source of regret that statistical information of a 
thoroughly reliable character, exhibiting the influence of the 
manifold occupations upon longevity in this country, can not 
be obtained; every effort has been made but with indifferent 
success. The nearest approach to the desired knowledge is 
furnished by the State of Massachusetts, in the Twenty- 
Second Registration Report, showing the number and average 
age of all persons over twenty years old who have died 
during the period of nineteen years and eight months, ending 
December 31, 1863. For Life Insurance purposes this report 
must necessarily prove of little value, for very many of the 
averages have been made from a number less than one hun- 
dred persons of a specified occupation. To prove of any 
practical benefit the average age should be computed from a 
number of not les3 than one thousand individuals of a speci- 
fied employment, and the larger the number from which the 
calculation is made the better. 

In addition to the Massachusetts Registration Report, 
which is here presented, will also be found a table by Mons. 
Lombard, exhibiting the average age attained in France by 
persons following the occupations therein named, The aver- 



14 



HINTS TO MEDICAL EXAMINERS. 



ages are believed to have been computed from several thou- 
sands of persons of each employment mentioned. In the 
absence of anything more reliable it is appended, but as a 
guide for this country it should be accepted with caution. 



OCCUPATION. 



All classes of occupations, 

1. Cultivators of the earth, , 

2. Active mechanics abroad, , 

Brickmakers, 

Carpenters, 

Calkers and Gravers, , 

Masons, 

Ship-Carpenters, 

Stone-Cutters, 

Tanners, 

3 Active mechanics in shops, 

Bakers, 

Blacksmiths, 

Brewers 

Card-makers, 

Carriage-makers, 

Chair-makers, 

Confectioners, 

Cooks, 

Coopers, 

Curriers, 

Cutlers, 

Distillers, 

Dyers 

Founders, 

Furnace-men, 

Glass-blowers, 

Hatters, 

Leather-dressers, 

Machinists, 

Millers, 

Musical Instrument makers, 

Paper-makers, 

Plumbers, 

Potters, 

Tallow-chandlers, 

Tinsmiths, 

Weavers, 

Wheelwrights, 

4. Inactive mechanics in shops, 

Barbers, 

Basket-makers, 

Bookbinders, 

Carvers of Stone and Marble, in doors.. 



77.188 

19.252 

5,745 

49 

3.202 

98 

801 

518 

477 

410 

7,025 

254 

1,398 

26 

134 

55 

35 

47 

545 

52 

58 

16 

80 

145 

56 

73 

217 

83 

933 

154 

9 

151 

36 

23 

37 

191 

207 

301 

8,867 

184 

89 

67 

30 



HINTS TO MEDICAL EXAMINERS. 



15 



OCCUPATION. 



No. oi 
Per- 
sons. 


Av. 

Age. 


58 


36.90 


43 


61.35 


50 


41.52 


233 


39.44 


815 


37.63 


336 


36.98 


5,469 


43.34 


759 


43.35 


24 


50.75 


14,733 


45.93 


76 


26.80 


138 


40.29 


14,351 


46.18 


16 


40.12 


2,920 


37.36 


16 


32.56 


264 


50.60 


192 


36.74 


86 


38.69 


8 


57.37 


30 


56.83 


1,230 


28.96 


165 


41.57 


530 


40.45 


724 


60.33 


5.020 


45.67 


79 


47.09 


1 


58.00 


20 


53.15 


43 


60.46 


4,927 


45.48 


7,272 


47.92 


3 


58.68 


67 


54.45 


73 


51.45 


1,293 


33.39 


105 


3960 


787 


64.61 


192 


48.31 


652 


47.62 


1.913 


52.70 


131 


38.54 


1,521 


46.81 


2,679 


50.24 


66 


48.70 


55 


41.91 


472 


59.25 


79 


41.63 


52 


39.33 


35 


45.37 


9 


63.11 


374 


56.11 


126 


40.66 



4. Cigar-makers. 

Clock (and watch) makers, 

Engravers, 

Jewellers, 

Operatives, 

Printers, 

Shoemakers, 

Tailors, 

Tobacconists, 

5. Laborers— no special trades, . . 

Brakemen, 

Drivers, 

Laborers, 

Workmen in powder-mills, . . . 

6. Factors laboring abroad, 

Baggage-masters, 

Butchers, 

Firemen and Engineers, 

Expressmen 

Lighthouse keepers, 

Sextons, 

Soldiers, 

Stablers, 

Teamsters, 

Weighers and Gaugers, 

7. Employed on the ocean, 

Fishermen 

Marines. 

Naval Officers 

Pilots, ' 

Seamen, 

8. Merchants, Financiers, Agent: 

Bankers. 

Bank officers, 

Brokers, 

Clerks 

Druggists, 

Gentlemen, 

Grocers, 

Manufacturers, 

Merchants, 

Railroad Conductors and Agents 
Traders, 

9. Professional men, 

Artists, 

Civil Engineers, 

Clergymen, 

Comedians, 

Dentists, . . . 

Editors, » 

Judges and Justices, 

Lawyers, 

Musicians, 



etc.. 



16 



HINTS TO MEDICAL EXAMINERS. 



OCCUPATION. 



No. of 
I Per- 

j sons 



Av. 

Age. 



9. Physicians, 

Professors 

Public Officers, . 

Surveyors, 

Teachers, 

10. Females, 

Domestics, 

Dressmakers, . . . 
Housekeepers, . . 

Milliners, 

Nurses 

Operatives, 

Seamstresses, . . . 
Shoe -Binders,... 
Straw-Braiders, 

Tailoresses, 

Teachers 



675 

22 

250 

55 

312 

3,625 

303 

118 

2.264 

65 

41 

413 

139 

33 

28 

119 

129 



55.86 
55.81 
53.81 
48.00 
38.71 
46.13 
47.21 
41.75 
50.11 
39 03 
60.90 
28.23 
44.19 
41.79 
37.28 
43 13 
29.12 



Below will be found the Table of Mons. Lombard, showing 
the average age attained, in France, by persons employed in 
the different occupations mentioned. 



OCCUPATION. 



Stone Cutter, 

Miller and Baker, 

Painter, ordinary, 

Carpenter and Joiner, . 

Sawyer, 

Butcher, 

Surgeon, 

Mason and Bricklayer, 
Poet, 



AV. 

AGE 



OCCUPATION. 



Philosopher. 
Gardner, . . . 
Statesman, . 
Merchant,.. 
Clergyman, 
Musician, . . 

Sculptor, 

Magistrate, 



AV. 

AGE 



59 
60 
61 
62 
63 
63 
63 
69 



TEMPERAMENT. 



It has been observed that the temperament of an individ- 
ual affords, to a certain extent, the key to a knowledge of the 
class of diseases to which he would be most liable, and con- 
sequently it is always desirable that the temperament of the 
applicant for insurance be carefully noted. 



HINTS TO MEDICAL EXAMINERS. 17 

Four temperaments, the Bilious. Nervous, Sanguine and the 
Lymphatic, with the combinations, Bilious- Lymphatic, Nervo- 
Sanguine, etc., constituting the mixed temperaments, are all 
that is essential to observe for insurance purposes. 

The tendency to paralysis, epilepsy, insanity and nervous 
diseases generally, would of course characterize the Nervous 
Temperament, while the Sanguine Temperament would predis 
pose its possessor to cardiac lesions, haemorrhages, fevers of 
an inflammatory type, acute rheumatism, congestions, etc. 
The Lymphatic or Phlegmatic predisposes to chronic maladies, 
debility, tubercular, scrofulous and dropsical affections. A 
fair complexion, pallid skin, languid circulation, softness of 
the muscles, and torpidity of the bodily and mental functions, 
characterizes this temperament. 

The Bilious Temperament will be recognized in individuals 
possessing a dark complexion, dark hair and eyes, firm flesh, 
energetic thought and action, and inclines the possessor to 
dyspepsia, hypochondriasis, and general disordered hepatic 
action, 

GENERAL REMARKS. 

It may here be well to remark that Examiners for Life 
Insurance are not required, as a general practice, to make a 
nice differential diagnosis defining the character of any 
organic lesion which may be discovered in an applicant. 
The physician is merely expected to ascertain if a lesion 
exist in any organ of which the integrity is essential to good 
health. It is not important that the Examiner should state 
whether a paralysis is due to apoplexy, mollities cerebri, or 
what other cause, the presence of the lesion. prevents a possi- 
bility of insurance, and, consequently, a knowledge of its 
cause is not material. When, upon examination, it is learned 
2 



18 HINTS TO MEDICAL EXAMINERS. 

that the applicant is free from disease, it is expected that the 
Examiner will furnish an intelligent opinion as to the proba- 
ble duration of applicant's health and life, i. e., give the Com- 
pany a reasonable guaranty that he will fulfil or go beyond his 
" expectation of life," aside from any fatal result from acci- 
dent, poison, epidemic, or infectious disease, which of course 
can not be foreseen. This opinion will be derived from a 
careful consideration of the family record, together with the 
inspection of the applicant. Further, the diathesis and 
temperament require particular attention, the first as exhib- 
iting the individuals predisposition to certain diseases rather 
than others, as for instance, the cancerous, scrofulous, rheu- 
matic or calculous diathesis and the temperament as indi- 
cating the diseases to which he would probably be subject, 
aside from diathetic influences. When a tendency to a disease 
is observed in an applicant who is at present in good health, 
the Examiner, before recommending the risk, should consider 
whether this tendency to disease will become early kindled 
into a fatal malady or remain latent throughout a long life, 
and this greatly depends upon influences of climate and 
occupation. 

The tendency to hepatic disease would be manifestly in- 
creased in a dry warm climate, while a cool moist region 
would exert a restraining influence and keep in subjection 
the predisposition. An indoor sedentary occupation would 
also prove prejudicial. Persons exhibiting tendencies to 
strumous and tubercular diseases would perhaps*attain to 
advanced age in an atmosphere warm and dry, but would 
almost surely succumb to that of a bleak, damp, chilly air. 
Frequently the Examiner will meet with robust but short 
lived applicants, who, although yet in vigorous health, can 
not be safely accepted, on account of family history and the 



HINTS TO MEDICAL EXAMINERS. 19 

personal surroundings pointing to a brief existence. On 
the other hand, persons are often observed apparently of 
delicate frame and weakly constitution, who are descendants 
of a race noted for length of life. Such an applicant, if free 
from disease and with a geod family record, could safely be 
accepted, notwithstanding delicacy of frame and constitution, 
while in the case of the robust person above cited the risk 
would be too great for the Company to incur. Long lived 
persons are always the ones desired. 

Paucity of evidence in the family history should lead to 
extra c\re in the personal examination of the applicant. 

PERSONS UNDER MEDICAL TREATMENT. 

No applicant while under medical treatment will be ac- 
cepted. Persons recovering from attacks of acute diseases 
must be fully restored to their usual state of health before 
examination for insurance. 

CORRECT ANSWERS. 

Be sure to answer all questions correctly, giving full and 
decided answers, yes or no, as the case may be. Applications 
are frequently returned to Examiners for correction, which 
is a source of delay, expense and annoyance to the Com- 
pany. If any disease has occurred, give the facts precisely, 
avoiding such phrases as " urinary trouble," "kidney diffi- 
culty,'* "throat disorder," "complication," etc. Terms which 
being too vague to convey any precise information produce 
an unfavorable impression as to the risk being a desirable 
one. 

In all cases where the Medical Examiner and the physi- 
cian to the party applying for insurance are identical, the 
blank headed "Questions to be answered by the physician 



20 HINTS TO MEDICAL EXAMINERS. 

of the party applying for insurance," should be filled out 
by the Examiner. 

PREVIOUS REJECTION. 

In case the application of a person to be examined states 
that the party has been rejected by some Company, learn if 
possible the cause of rejection and note if the cause still 
exists. Occasionally persons are declined for diseases which 
existed at the time of making application but subsequently 
disappeared, or an error in diagnosis on the part of the for- 
mer Examiner may have been the cause of the Company 
declining the risk. 



METHOD OF EXAMINATION. 



I 



T is desirable to have some regular system or method 



§j of procedure in conducting an examination, for exam- 
ple, taking first the pulse rate standing and sitting, then 
exploring the chest, after which take the chest mensuration, 
etc. The acts of inspiration and expiration will cause the 
pulse to become accelerated, hence the reason for taking the 
pulse rate before examining the thorax. 

Observe that the individual to be examined is identical 
with the one whose name is written in the application by 
the Agent. See that the name and residence correspond. 
Errors have occurred and fraud has been perpetrated by 
designing parties and applications written on invalid lives, 
persons in health being presented for examination. 

The certificate of examination must in all cases be in the 
hand writing of the Medical Examiner. To his signature should 
be affixed his college degree, as well as a specification of the 
place at which he, as an Examiner is located. 

SUPERFICIAL EXAMINATIONS. 

Applicants should not be hastily examined. Sufficient time 
should be given to each case presented for a careful and 
searching examination. Observations hastily made must 
necessarily prove unreliable, and are, to say the least, super- 



22 HINTS TO MEDICAL EXAMINERS. 

ficial and unsatisfactory. The Company expects the Exam- 
iner to exert his best skill in its behalf. He is remunerated 
with a liberal fee, whether the applicant is accepted by the 
Company or not. Very many individuals fear an examina- 
tion and become excited, causing the pulse to vary much 
from its accustomed rate. In such cases remarks of a pleas- 
ant character from the Examiner, extraneous to the business 
in hand, will have a tendency to calm the fears and restore 
the pulse to a more natural condition. Should this or some 
other method fail, the examination had better be postponed 
until a more favorable time. Deprivation of accustomed sleep, 
excitement incident to business, a full stomach, or a very 
rapid walk to the office of the Examiner will in many per- 
sons cause similar conditions of the pulse. 

THE PULSE. 

The pulse requires very close observation and attention as 
to its character, and all variations from a perfectly healthy 
standard should be fully noted. In the Eastern States the 
pulse rate of an adult in good health ranges from 70 to 75 per 
minute, while in the North-Western States it averages more, 
being from 75 to 80. A difference of from four to ten beats 
per minute is observable in the pulse rate between the stand- 
ing and sitting positions, and it is very seldom that less than 
three beats is found, yet Examiners frequently report the 
rate the same for the two positions, which must be the result 
of guessing rather than observation. 

This Company does not accept applicants under the age of 
fourteen years. The rate of the pulse at the age of puberty 
should not vary much from 85 to 90. Below these figures 
Examiners sometimes report the pulse, which would, in a 
large proportion of cases, indicate carelessness on the part 



130 to 140 


120 to 


130 


100 




85 to 


90 


70 to 


75 


75 to 


80 


65 to 


70 



HINTS TO MEDICAL EXAMINERS. 23 

of the physician, or a diseased and unhealthful condition of 
the applicant. The annexed table may be considered in the 
main correct. 

Pulse at birth, . . . . 

" During infancy, .... 

" In childhood, 

" Of youth, 

" Of adult male, ..... 
11 Of adult female, 



When the pulse is habitually or temporarily below 58 sit 
ting, or above 88 standing, it will prove a cause for rejection, 
unless explained as a personal peculiarity or idiosyncrasy. 
An irregular pulse also rejects, unless explained as peculiar 
to the applicant. The intermittent pulse most authorities 
assert to be indicative of cardiac lesion or brain disease, but 
not always. Excessive use of tobacco has also produced it in 
some instances. Intermission, due to valvular defect, may 
disappear temporarily from acceleration of the pulse by exer- 
cise, emotion, etc. 

CHEST MENSURATION. 

Chest measurement should be made with an ordinary tape 
line, over the nipples and under the inferior angles of the 
scapulas, and over but a single flannel garment, during full 
inspiration and forced expiration. The average size of the chest 
of healthy adult males, when as free from air as possible, 
varies from thirty-two to thirty-four inches; the average 
expansion is from two to four inches. An adult applicant 
exhibiting a less expansion than two inches it would not be 
safe to accept. In cases where the expansion is slight, a few 



2£ 



HINTS TO MEDICAL EXAMINERS. 



moments devoted to repeated trials will elicit, by practice, a 
marked improvement, most persons being ignorant concern- 
ing the full inflation of their lungs. 

The annexed table gives the proper weight and chest 
expansion to height, and the more closely an applicant approx- 
imates to this standard the better the risk, other things being 
equal. 

HEIGHT TO WEIGHT AND MEASUREMENT OF CHEST. 



Height. 


Weight. 


Chest. 


Height. 


Weight. 


Chest. 


5 ft. 1 inch. 
5 " 2 " 
5 " 3 " 

5 " 4 " 
5 " 5 " 
5 " 6 " 


120 lbs. 
125 " 
130 " 
135 " 
140 " 
143 " 


34.06 in, 
35.13 " 
35.70 " 
36.26 " 
36.83 " 
37.50 " 


!5ft. 7 inch. 
5 " 8 " 
5 " 9 < ; 
5 " 10 " 

5 " 11 " 

6 " " 


145 lbs. 
148 " 
155 " 
160 " 
165 " 
170 " 


38.16 in. 
38.53 " 
39.10 " 
39.66 " 
40.23 '•'• 
40.80 " 



Of course this standard must necessarily be departed from 
in some instances, and the applicant yet prove a desirable 
risk. The above table of height, weight and chest measure- 
ment is the one used in England and also by the Companies 
of this country. 

The propriety of using this table, as a standard for Ameri 
cans, has been questioned by several medical men, upon the 
supposition that the physique of Europeans is greatly in 
excess of that of the native male population of this country. 
This view is erroneous. A considerable proportion of the 
native born insured lives in the United States claim foreign 
parentage, in some instances one and in others both parents 
are of foreign birth. Between this class and those of foreign 
birth, as well as natives of this country whose parents were 
also born here, but little if any appreciable difference exists 
upon the average. 

In evidence of this the remarks of Dr. Fish, of New York 
city, are of interest: "A New York surgeon examined 8,700 



HINTS TO MEDICAL EXAMINERS. 25 

recruits for the United States Army, of whom 4,538 were 
Americans, 1,694 Irish, 1,453 Germans, 315 English and 
Scotch, 135 French and 545 belonging to twenty-six other 
nations. He made a strict examination, to determine whether 
there was any foundation for the frequent affirmation of the 
English journals that the physical man in America was 
deteriorating. The Americans in New York city were, of 
course, not above the average of American physique, yet his 
examination puts them ahead. In stature the American 
born ranks the highest, the English next, the Irish next, the 
Germans next and the French last. In regard to their phys- 
ical conformation, he divided the recruits into four classes, 
and found the American to possess the highest rate of prime 
physique. Of American born recruits 47.5 per cent, had a 
prime physique, the Germans 40.75 per cent., and the Irish 
85 per cent. He arrived at the conclusion that no race can 
show a larger proportion of osseous and muscular develope- 
ment than the American.'' 

THE RESPIRATORY ORGANS. 

The ratio of respirations to pulsation is as one to four and 
five in healthy adults, and any marked deviation from this 
rule should excite particular attention on the part of the 
Examiner The following table will prove instructive: 

QUETELET'S TABLE. 





INSPIRATION. 


A(.tE. 


AV. MAX. 


MIX. 


At Birth 


44 

26 
20 


70 
32 
24 


23 


At 5 Years, 




From 15 to 20 Years 


16 


From 20 to 24 Years 


187 24 
16 21 
18.1 23 


14 


From 25 to 30 Years, 


15 


From 30 to 50 Years, 


11 











26 HINTS TO MEDICAL EXAMINERS. 

The lungs require always a very careful inspection, and par- 
ticularly should a searching examination be made in cases 
where the family history exhibits hereditary tendencies to 
phthisis, for often in persons apparently the "picture of 
health" this insidious disease lurks, awaiting only a favor- 
able opportunity to show itself. Persons in advanced stages 
of this malady seldom seek insurance. 

AYith reference to the hereditary transmission of phthisis 
or insanity, it has been observed that the mother more readily 
transmits these diseases than the father, and an answer to the 
question, "Which parent does the applicant most resemble in 
temperament?'' is very important where a parent has died of 
consumption or other hereditary disease. Carefully observe 
whether any predisposition exists in the applicant to the 
disease of which either parent may have died. 

The fact that the greater part of the losses annually paid 
by Life Insurance Companies is from death by consumption, 
shows that the greatest care is necessary on the part of 
Examiners in recommending risks. Apoplexy and disease 
of the heart also form a large proportion of the causes of 
death upon which losses are paid. The experience of nearly 
all companies prove that the greatest number of deaths from 
above causes result in the space of from two to five years 
after insurance is effected, thus establishing the fact that the 
disease in an incipient state, or at least a strong predispo- 
sition to the malady which eventually proved fatal, existed 
in the applicant at the time of the medical examination. 

BRONCHITIS, EMPHYSEMA AND ASTHMA. 

The existence of either bronchitis or emphysema is a cause 
for rejection. Asthma — which in a general sense is under- 
stood to mean a spasmodic contraction of the circular mus 



HINTS TO MEDICAL EXAMINERS. 27 

cular fibres of the bronchial tubes — is very rarely simply 
nervous in its origin, and but a very small proportion of the 
cases presenting themselves to the Examiner can be safely 
accepted. The idea so commonly received that asthmatics 
seldom die of phthisis, has led some physicians to look 
favorably upon such cases and recommend them for insur- 
ance, overlooking, it would seem, the fact that the presence 
of asthma often indicates the existence of an organic lesion of 
the heart brain, medulla oblongata, or lungs, and is also fre- 
quently associated with some degree of bronchial inflamma- 
mation. It has been observed that asthmatic attacks may 
both cause and be the result of heart disease, and, in the 
case of females, is often diagnostic of uterine affections. 
Subjects of asthmatic attacks should receive a rigid exami- 
nation, with a view of ascertaining the source, the Examiner 
recollecting that emphysema is sometimes associated with 
asthma as a cause. Asthmatic applicants are second class 
risks, and, if recommended by the Examiner, it should be 
upon some short endowment plan. These remarks have refer- 
ence only to the most favorable cases of asthma. In brief, 
this Company does not want asthmatics of any kind. 

But slight difficulty arises in detecting acute bronchitis, 
and the Examiner will seldom meet with the disease in this 
form; but cases of the chronic variety will often present 
themselves, and, as is known to every medical man, are not 
so readily diagnosed, particularly if it should chance to be 
at a season of the year when the characteristic symptoms of 
this disease are comparatively quiescent, as during the sum- 
mer months, or a case where the symptoms are not very 
marked. Many victims of chronic bronchitis are quite free 
from suffering throughout the warm season, experiencing 
distress only upon the approach of winter and during the 



28 HINTS TO MEDICAL EXAMINERS. 

spring months. Persons past the middle period of life are 
as a general rule the most liable to the affection, and the 
majority of cases of "winter cough," to which very many 
individuals are subject at this time of life, is the result of 
bronchial inflammation of a low, lingering type. 

Not only may danger be apprehended from bronchitis 
even when uncomplicated, but additional importance should 
be attached to the disease from the fact that it is often sym- 
tomatic of the tuberculous diathesis as well as frequently 
being associated with disease of the heart. Occasionally it 
can be traced to syphilis, and according to standard author- 
ities is complicated with Bright's disease in seven-eighths of 
the cases of that affection. 

The type of bronchitis known as capillary, or where the 
finer tubes are affected, is chiefly observed among children 
or adults of advanced age, and in the latter is often associ- 
ated with an emphysematous condition of the lungs. Sub- 
crepitant or sibilant rales with marked dyspnoea are promi 
nent symptoms. The Examiner will not often meet with 
this variety of the disease. 

CONSUMPTION OF THE LUNGS. 

This, like other diseases, is most likely to occur when it 
has existed in the ancestry. Careful investigation should 
therefore always be made as to the health of the applicant's 
parents and grand parents, if living, as well as to the cause 
of death if deceased. But it will be remembered that this 
disease is largely due to climatic influences, especially to dampness 
of soil and atmosphere. This fact explains the excessive mor- 
tality from phthisis in certain sections and regions of country 
over and above that of other sections. 

Where the family record of an applicant states that either 



HINTS TO MEDICAL EXAMINERS. 29 

parent has died of "acquired consumption," the Examiner 
should be very particular to learn from the applicant, or 
other source, as to duration of the disease, under what con- 
ditions manifested, etc., and from information thus elicited, 
satisfy himself with regard to the true character of the 
malady. It is very probable that consumption, in common 
with some other diseases, may be acquired. Habits of life, 
unhealthful occupation and climate may conduce to the 
acquisition. That the influence of climate is more marked 
in consumption than in rheumatism, is apparent to all med- 
ical men. A consumptive tendency may be hereditary, 
either because the ancestors were consumptive, or because 
they transmitted some feeble state that favored the influence 
of climate or habits of life. 

Many applications are received where the family record 
attributes the mothers death to "childbirth." Very many 
cases thus reported are, in reality, the result of phthisis, as 
further investigation has proved. It is well known to med- 
ical men that females who are victims of lung disease fre- 
quently conceive and carry children until full term, (the 
general health being much improved for the time being,) 
and at, or shortly after, confinement succumb to the lung 
disease. 

SPITTING OF BLOOD. 

The attention of Examiners is particularly called to appli- 
cants who may have at any time suffered from a loss of 
blood, expectorated or vomited. In such cases it is abso^ 
lutely essential that full particulars as to number of attacks, 
age at which they occurred, and, if a female, whether in the 
Examiner's opinion the heemorrhage was due to vicarious 
menstruation, (Deviation des Regies.) Learn if the blood came 



30 HINTS TO MEDICAL EXAMINERS. 

from the lungs (haemoptysis,) or stomach, (hcematemesis,) 
or from the mouth, (bleeding gums,) or nasal cavities. In 
a large proportion of cases where the bbod coughed up is 
bright in color, at times frothy and preceded by a saline 
taste, it would be considered symptomatic of grave lung 
disease. Haemoptysis occurring in persons under twenty- 
five or thirty years of age would indicate phthisis, and 
is a well known precursor of that malady. Haemorrhage 
from the lungs, occurring between the ages of thirty and 
forty, would point to probable cardiac lesion, to wit: Mitral 
disease, hypertrophy and dilatation of the left ventricle, 
also to disease of the larger vessels of the chest. In pneu- 
monia it sometimes occurs, but where an applicant has 
recovered from the pneumonia and possesses a good fam- 
ily record, it will not prove a barrier to insurance, unless 
he has had three severe attacks of this disease, under which 
circumstance the risk should be declined. Where hoemate- 
mesis, oy vomiting of blood, has occurred, and positive evidence is 
produced that it w T as not in consequence of malignant or other 
diseased condition of the stomach, it will not prove objec- 
tionable, if the family history is good and the applicant in 
sound health. However, since there is usually difficulty in 
gaining positive information regarding the source of the 
blood discharged, it is safest to decline such applicants. 

ORGANS OF CIRCULATION. 

The organs of circulation demand careful attention. Ob- 
serve whether the heart occupies its normal position. Notice 
whether there is any intermission or irregularity in the 
beat, if gentle or violent, and whether the impulse against 
the chest is coincident with the first sound. Abnormal heart 
sounds in persons subject to repeated attacks of inflamma- 



HINTS TO MEDICAL EXAMINERS. 31 

lory rheumatism are common. Dilatation, hypertrophy and 
the various valvular diseases to which the heart is liable, 
will not escape the attention of the skillful Examiner. All 
cardiac lesions and deviations from the normal standard 
should be reported in the examination forwarded to the 
General Office of the Company. 

In cases where there is doubt regarding the heart being 
in a perfectly normal condition, advise violent exercise for a 
a few moments, running rapidly about an apartment or up 
a flight of stairs will enable the Examiner to decide if any 
disease exist. Cases of functional cardiac disturbance due 
to the use of tobacco, or cases of excessive impulse or other 
deranged action of the heart, due to enervation, the result 
of onanism, sexual excesses, anaemia, or whatever cause, 
must be first remedied by proper treatment before insurance 
can be effected. 

A considerable proportion of deaths resulting from disease 
of the heart occur suddenly, and without any premonitory 
signs, outside of what would most probably be revealed by a 
careful examination of the organ by a competent medical 
man. To all external appearance there is in many instances 
nothing to indicate any departure from a condition of sound 
health, and yet, Companies are frequently called upon to 
settle losses the result of death from " heart disease" which, 
so far as the records of the Company show, was never diag- 
nosed during life, or, at least, never reported if known to the 
Examiner, but which is abundantly proven to exist by an 
autopsy. This simply suggests the necessity for extreme 
care in examining applicants and recommending them for 
insurance. 

The annexed table, indicating lesions of the lungs, may be 
of use in some cases: 



32 HINTS TO MEDICAL EXAMINERS. 

TABLE DEDICATING PULMONARY DISEASES. 



SOUNDS OBSERVED. 


DISEASE ASSOCIATED j RELATIVE TO INSPIRA- 
. WITH. TION AND EXPIRATION. 


Mucous rale. 


Secondary bronchitis j With either or with 
with secretion. both acts. 


Sibilant rale. 


Capillary Bronchi- 
tis. 


With either or both. 
Oftener with inspira- 
tion. 


Sonorous rale. 


Primary Bronchitis. 


With either or both. 
Oftener with expira- 
tion. 


Cavernous. 


Tuberculous excava- 
tions. Vomica from 

abscess. 


With either or both. 
More frequently with 
inspiration. 


Crepitant rale. 


Pneumonia. 


Exclusively with in- 
spiration. 


Sub -Crepitant rale. 


Pneumonia. Period 
of resolution. 


With either or both 
acts. 


Humid crackling. 


Softening in tuber- 
cle. 


More distinct in in- 
spiration. 


Dry crackling. 


Early stage of j Exclusively with in- 
Phthisis. j spiration. 



— 



The mucous, sibilant, sonorous, crepitant and sub-crepitant 
rales, when limited to a small space at the summit of the 
chest, indicate tuberculosis. 

ANEURISM OR OTHER TUMORS. 

Aneurism or other tumors, if they exist and are sufficiently 
advanced, will manifest their presence by such disturbance 
of the respiratory organs and circulation as scarcely to fail 
in attracting immediate attention. 

When examining those who have passed the middle period 
of life, the thoughtful physician will recollect the tendency 
to fatty degeneration in the muscles of the heart, and in the 
coats of the great vessels causing aneurisms, and in those of 



HINTS TO MEDICAL EXAMINERS. OO 

the brain tending to apoplexy. The presence of the arcus 
senilis (in the eye indicating, at least, fatty degeneration of 
the edge of the cornea,) renders some or all of these conditions 
probable. Yet, it will be remembered that its absence fur- 
nishes no aid in diagnosis, for it is sometimes not exhibited 
even in extensive and fatal internal fatty degeneration. 

DISEASES OF THE BRAIN. 

Diseases of the brain and spinal cord, both functional and 
organic, insanity, ramollissement, atrophy, chronic menin- 
gitis, apoplexy, paralysis and the long train of morbid brain 
symptoms, due to the excessive use of opium, tobacco, "hash- 
eesh/' etc., will, of course, be detected, and prove a cause for 
rejection at all times. 

INTEMPERANCE. 

The series of morbid phenomena produced by the excessive 
use of alcoholic drinks, (Alcoholismus,) so frequently encoun- 
tered among men in every grade of society, will not escape 
proper attention. No one will write himself down an inebri- 
ate, yet there must be a beginning somewhere, and the med- 
ical man is asked the question direct. 

Reformed inebriates are not acceptable risks, the contin- 
ued use of alcohol leaving in its wake effects which long- 
periods of complete sobriety fail to remove. Undoubted 
hereditary tendencies exist with reference to the transmis- 
sion of the morbid appetite for intoxicating drinks, and 
"atavism'' in intemperate families is as frequently observed 
as in families afflicted with phthisis pulmonalis, or insanity. 

Individuals who indulge in occasional "sprees" come 
decidedly under the head of intemperate, notwithstanding 
there may be intervals of temporary sobriety, and this class, 



34 HINTS TO MEDICAL EXAMINERS. 

as well as the confirmed drinker, must be declined. The 
same holds good with persons who habitually indulge in the 
use of opium, morphine, cannabis indica, or any other unnat- 
ural stimulant. 

URINARY ORGANS. 

The condition of the urinary organs demand very partic- 
ular attention. Permanent strictures, enlarged prostate, 
and the presence of calculi seriously compromise the func- 
tions and structure of the bladder, which, in turn, leads to 
fatal disorganization of the kidneys. If pain of a persistent 
character has existed or exists in the region of the kidneys, 
accompanied with a puffy or slightly oedematous condition of 
the face, the urine should at once be subjected to an exam- 
ination and the proper test applied. Morbus Brightii is 
insidious in its approach, an albuminous condition of the 
urine and occasional pain (sometimes no pain,) or uneasi- 
ness in the region of the kidneys, frequently mark the 
invasion of this fatal malady. In all cases of excessive 
urination the urine should likewise be subjected to analy- 
sis and if the presence of saccharine matter is detected, the 
applicant must be declined. The specific gravity of the 
urine can readily be obtained by an ordinary urinometer. 
By comparing the number on the stem to which the instru- 
ment sinks with the corresponding number in the annexed 
table, it will at once be apparent how much the specimen 
varies from a normal standard. 

If, after boiling in a test tube, the urine becomes turbid 
and does not clear up on the addition of a few drops of nitric 
acid, and the specific gravity comes within the limits of 
Bright's disease, the risk cannot of course be accepted. 

The tests for diabetic urine are many; perhaps Trommcrs 



HINTS TO MEDICAL EXAMINERS. 



35 



Test is as accurate as any. It may be applied by adding a 
drop or two of a solution of sulphate of copper to the sus- 
pected fluid in a test tube. Liquor potassse is then added in 
excess and the mixture boiled. If the proper proportions 
have been observed a red deposit of the suboxide of copper 
is precipitated if there be sugar present. 



SPECIFI 
QBAVITl 


FLUIDS EXAMINED. 




\ 1000 


Distilled water 




1005) 
1010 \ 
1015 J 


Average in Bright's disease, . 

May go as low as 


1013 
1004 


1020) 
1025 / 


Average limits of healthy urine. 




10301 
* 1035 
1040 
1045 - 
1050 
, 1055 
1060 


Limits of diabetic urine 

Average, 


1040 



USE OF THE SPIROMETER. 
J In England and also upon the continent Dr. Hutchinson's 
Spirometer, or instruments of equal merit by other makers, 
are in use among the Examiners of some of the leading Life 
Companies, and are reported as assisting very materially in 
establishing the degree of vital capacity of candidates for 
insurance. The spirometer, it will be remembered, is an 

instrument for measuring the volume of air expired from the 

i 

lungs, and in the absence of such instruments among Exam- 
iners in this country, the remarks of the distinguished Dr. 
Tilbury Fox, of London, with tables compiled by Dr. Hutch- 

| inson will prove interesting. Dr Fox says: 



36 



HINTS TO MEDICAL EXAMINERS, 



"The vital capacity volume is affected by height, by at- 
titude, by weight, by age, and by disease. 

"the vital capacity as affected by height. 
From a very large number of experiments, Dr. Hutchinson 
has deduced the curious fact that the height of an individual 
is the chief condition which regulates his vital capacity, and 
he lays down the following rule: That in the erect position, 
for every inch of stature from five to six feet, eight additional 
cubic inches of air, 60° Fahr., are given out in one volume, 
by the deepest expiration, immediately following the deepest 
inspiration. This table is intended to show the capacity in 
health and in the three stages of phthisis. 



Height. 




Capacity 




Capacity in 






in Health. 


Phthisis Pulmonalis. 


Ft. In. Ft. 


In. 


Cub. In. 


1st Stage. 
Cub. In. 


2d Stage. 
Cub. In. 


3d Stage. 
Cub. In. 


5 to 5 


1 


174 


117 


99 


82 


5 1 " 5 


2 


182 


122 


102 


86 


5' 2 " 5 


3 


190 


127 


108 


89 


5 3 " 5 


4 


198 


133 


113 


93 


5 4 " 5 


5 


206 


138 


117 


97 


5 5 " 5 


6 


214 


143 


122 


100 


5 6 " 5 


7 


222 


149 


127 


104 


5 7 " 5 


8 


230- 


154 


131 


108 


5 8 " 5 


9 


238 


159 


136 


112 


5 9 " 5 


10 


246 


165 


140 


116 


5 10 « 5 


11 


254 


170 


145 


119 


5 11 " 6 





262 


176 


149 


123 



"This reads thus: A man between 5 ft. 7 in. and 5 ft. 8 in. 
in height, should be able to breathe, in health, 230 cubic 
inches; in the first stage of consumption this will be reduced 
to 154; in the second to 131; and in the third to 108 cubic 
inches. A knowledge of these facts on the part of the prac- 
titioner is of importance in reference to the examinations of 



HINTS TO MEDICAL EXAMINERS. 37 

persons assuring their lives, in guiding him in doubtful 
cases. 

"weight as affecting the vital capacity. 

"In examining diseases of the lungs, the indications afford- 
ed by the weight of the individual are invaluable. One of 
the first signs of disease, generally, is loss of weight; a steady 
loss always precedes consumption, and is the earliest symp- 
tom of tubercular disease. Dr. Hutchinson has observed, 
that a slow and gradual loss is more serious than a rapid and 
irregular diminution. A person may lose weight, but he 
cannot do this gradually without some severe exciting cause. 

"Weight in excess begins mechanically to diminish the 
breathing movements when it has increased to 7 per cent, 
beyond the mean weight; and from this point the vital capa- 
city decreases 1 cubic inch per lb. for the next 35 lbs. The 
ordinary weight increases with the height, probably about 6 j 
lbs. per inch of stature. It is unnecessar}^, however, to make 
the correction for weight, unless it be much in excess. From 
an examination of 2(350 healthy men at the middle period of 
life, Dr. Hutchinson has deduced the following table: 



Exact Stature, j 


Mean We] 


ght. 


Weight increased by 
7 per cent. 


Ft. 


In. j 


St. 


lbs. 


lbs. 


St. 


lbs. 




lbs. 


5 


1 


8 


8 or 


120 


9 


2 


or 


128 


5 


2 


9 


" 


126 


9 


9 


tt 


135 





3 


9 


7 " 


133 


10 


2 


it 


142 


5 


4 


9 


13 " 


139 


10 


9 


tt 


149 


5 


5 


10 


2 " 


142 


10 


12 


a 


152 


5 


6 


10 


5 " 


145 


11 


1 


it 


155 


b 


7 


10 


8 " 


148 


11 


4 


a 


158 


5 


8 


11 


1 " 


155 


11 


12 


a 


166 


5 


9 


11 


8 " 


162 


12 


5 


ti 


173 


5 


10 


12 


1 " 


169 


12 


13 


it 


181 


5 


11 


12 


6 " 


174 


13 


4 


it 


186 


G 





12 


10 " 


178 


13 


8 


it 


190 



00 HINTS TO MEDICAL EXAMINERS. 

"This table reads: A man of 5 ft 8 in. should weigh 11 st. 

1 ft)., or 155 ft)s., (14 ft)s.=l stone;) he may exceed this by 7 
per cent., and so attain 11 st. 12 lbs., or 166 ft)s., without 
affecting his vital capacity; beyond this rate his respiration 
becomes diminished. 

"AGE AS AFFECTING THE VITAL CAPACITY. 

"The vital capacity is found to be at a maximum between 
the ages of thirty and thirty-five, though the effect of age is not 
very manifest, until a person has attained fifty-five years, when 
the capacity diminishes sufficiently to render it necessary to make 
a subtraction. This we must do according to the annexed 
table : 



Height. 




Mean. 




Minimum. 


Ft. In. Ft. In. 


Age. 


Age. 


Age. 


16 per cent. 


15 to 55 


55 to 65. 


G5 to 75. 


below mean. 


5 to 5 1 


174 


163 


161 


146 


5 1 " 5 2 


182 


173 


168 


153 


5 2 " 5 3 


190 


181 


175 


160 


5 3 " 5 4 


198 


186 


182 


166 


5 4 " 5 5 


206 


196 


190 


173 


5 5 " 5 6 


214 


203 


197 


180 


5 6 " 5 7 


222 


211 


204 


187 


5 7 " 5 8 


230 


219 


212 


193 


5 8 " 5 9 


238 


226 


219 


200 


5 9 " 5 10 


246 


234 


226 


207 


5 10 " 5 11 


254 


242 


234 


213 


5 11 " 6 


262 


249 


241 


220 



"Thus it appears that a man 5 ft. 8 in., of the mean weight, 
may be expected to breathe 230 cubic inches until the age of 
fifty-five, 219 cubic inches from fifty-five to sixty-five, and 
212 from sixty five to seventy-five years of age. The vital 
capacity is somewhat reduced by a moderate meal, and by a 
full meal 9 to 14 inches. 



HINTS TO MEDICAL EXAMINERS. 39 

"In all the foregoing calculations, it is supposed that the 
patients are dressed in ordinary *attire. We therefore have 
to make no allowance for boot-heels, weight of dress, &c. It 
may be remarked, however that M. Quetelet estimates the 
average weight of the clothes, at different ages, as one- 
eighteenth of the total weight of the male body, and one- 
twenty-fourth of the total weight of the female. The value 
of spirometry in life assurance, in the detection of lung dis- 
ease, is very great." 

SPHYGMOGRAPHY AND THERMOMETRY. 

Medical writers, both in England and this country, have 
called the attention of the medical profession and insurance 
corporations to the value of thermometry and the sphygmo- 
graphin clinical observations and the selections of candidates 
for life insurance. The sphygmograph is described as "an 
instrument by the use of which the pulsations of the radial 
artery are represented in diagram. A sensitive lever, armed 
with a point at right angles to the shaft, is made to move up 
and down by placing one end of it over the radial pulse, the 
point is then made to come in contact with a piece of smoked 
glass or paper, which moves along in front of it. A curved 
line is therefore written by the moving point upon the moving 
glass or paper.' 7 The pulse is written off as it is called. 
Pulse writing is another term for sphygmography. In the 
hands of experts, or those versed in the correct use of the 
thermometer and sphygmograph, much may be learned in 
determining the vitality and expected longevity of appli- 
cants. When the "waves of circulation" are blunted or 
distorted, as would be exhibited by the sphygmograph, 
thereby varying from a diagram indicating a condition of 
health, the attention of the Examiner would be called to the 



40 HINTS TO MEDICAL EXAMINERS. 

probable existence of a cardiac lesion, aneurism, some form 
of brain disease, or senile degeneration of the arterial system, 
which would in many cases defy the best skill of the physi- 
cian to detect by physical exploration. The thermometer, 
when exhibiting a persistent increase or decrease of the 
normal temperature of the body would be additional evidence 
of the presence of a pathological condition which would 
render the applicant an unsafe risk for the company. Ac- 
cording to Dr. Aitken a rise of about 99.5° F., or a depression 
below 97.3° F., is a sure sign of some kind of disease, if the 
change is persistent. 

HERNIA. 

The great liability to strangulation of most if not all vari- 
eties of rupture, necessarily renders individuals the subjects 
of them second class and undesirable risks. Several life 
companies decline all applicants with rupture, excepting, 
however, one variety, to wit, single reducible inguinal hernia. 

Among adults it is estimated that one out of every fifteen 
persons are ruptured. The existence of hernia, even where 
a nicely adjusted truss is constantly worn, renders the risk 
less desirable, and all cases of double hernia positively decline, 
notwithstanding a proper truss may be in use. 

Any form of hernia in females will prove ample cause for 
rejection. 

The physician will not forget that operations for the cure 
of hernia are not always effectual, and that cases apparently 
cured by irritation of truss, or by the knife, upon absorption 
of the deposition, are more difficult of cure than at first. 
Such cases should not be accepted for insurance. 

Crural and inguinal hernia are considered more dangerous 
than umbilical. 



IIIXTS TO MEDICAL EXAMINERS. 



41 



Examiners should carefully diagnose each case presented, 
giving the company the benefit of any doubt which may 
occur to them regarding the perfect safety of the risk. All 
cases of rupture should be accurately noted and definitely 
explained as to variety, extent, etc., upon the application 
sent to the Home Office. 

PREDISPOSITION TO DISEASE. 

That persons frequently inherit from parents their consti- 
tutional peculiarities, and the morbid tendencies growing 
©ut of them, is as apparent as that they resemble them in 
features, form and traits of character. With the exception of 
syphilis — in a general sense — '-diseases are not inherited, 
but only those peculiarities of structure or constitution 
which predispose to them. For instance, infants are not 
born with gout, rheumatism, calculus, phthisis, etc., but only 
with those conditions of system which favor the development 
of these affections, when other causes co-operate. 1 ' The prin- 
cipal hereditary diseases are syphilis, scrofula, gout, con- 
sumption, epilepsy, insanity, cancer, asthma; psoriasis and 
calculus. In some instances the hereditary tendency is so 
great that the disease becomes developed, notwithstanding 
the utmost efforts to prevent it, as is abundantly illustrated 
in affections of the lungs and brain. The disposition to 
convulsions, hydrocephalus, idiocy, syphilis and scrofula, is 
most apparent during the early period of life; to epilepsy 
and phthisis about the age of puberty; to gout, rheumatism 
and various nervous diseases, during the years of maturity, 
and to cancer, asthma and paralysis at chiefly advanced 
stages of life. The inheritance may proceed from one parent 
only, or from both. Where from one parent only, the dispo- 
sition is often slight, with perhaps the exception of phthisis, 



42 HINTS TO MEDICAL EXAMINERS. 

and the offspring frequently escape any manifestation of the 
affection, but where the inheritance is from both parents the 
case is the reverse, and the safety very greatly diminished. 

DISEASES OF THE HEART IN EITHER PARENT. 

A predisposition to cardiac disease is readily transmitted 
to offspring, and where a parent of the applicant has died of 
such disease, the physician should not fail to exercise more 
than usual care in his examination, making every effort to 
discover the presence of disease, and should he entertain a 
doubt regarding the safety of the risk, the Company expects 
the benefit of it, 

CEREBRAL APOPLEXY. 

Predisposition to this malady, by inheritance, is so common 
that it is scarcely necessary to allude to it here, and the 
examining physician will recollect that the so called " apo- 
plectic habit,'' "persons with large heads, short necks, red 
and turgid faces, full habit of body, and generally of san- 
guineous temperament" are not the individuals who become 
subjects of apoplexy, although commonly conceived to be the 
class most liable to this disease. While it is probable that 
some persons possessing the above described physical con- 
formation die of apoplexy, by far the largest number of 
apoplectic patients will be found among individuals who do 
not possess these characteristics, and, indeed, tall, thin, pale 
faced persons form a goodly proportion of the victims of this 
disease. The ages at which the greatest tendency exists are 
from 40 to 70, and very few cases occur under 25 years of 
age. Predisposition to apoplexy of any kind of course pre- 
cludes insurance. 



HINTS TO MEDICAL EXAMINERS. 43 

RHEUMATISM. 

Persons subject to inflammatory or metastatic rheumatism, 
even where the heart is yet in a perfectly healthy condition, 
are unfit for purposes of insurance. The excess of fibrin in 
the blood, which marks this diathesis, often occasioning de- 
posits about the pericardium and valves of the heart, or, in 
the form of embolia obstructing the action of the kidneys or 
liver, at times ending in fatal disorganization. Occasionally 
the fibrous deposit becomes detached and circulating in the 
arteries is carried to the brain, its presence there causing 
hemiplegia. 

Cases of hereditary rheumatism are sometimes encountered 
in applicants, and under the most favorable circumstances 
it impairs the risk, to say the least. Syphilitic rheumatism, 
as well as all other manifestations of syphilis is a sufficient 
cause for rejection. 

SUDDEN DEATHS. 

Death, resulting simply from old age, without the influence 
exerted by some diseased condition of the organism, is ex- 
tremely rare. Nearly every death is the result of disease or 
accident, and, in case of death from disease, it may occur in 
two ways, — either suddenly, the transition from life to death 
occurring in a moment and without premonotory sign, or 
slowly and gradually, as the termination of some lingering 
malady. 

"The most frequent causes of sudden deaths,'' says Thomas 
Tanner, M. D., of London, "are, apoplexy; rupture of an 
aneurism or large blood vessel into one of the three great 
cavities of the body; disease of the valves of the heart— the 
liability being greater in disease of the aortic valve than in 
mitral valvular disease; rupture of the heart, from fatty 



44 HINTS TO MEDICAL EXAMINERS. 

degeneration; clotting of blood in the heart; laceration of the 
chordoe tendineae; asphyxia, from obstruction of the glottis, 
or the bursting of purulent cysts into the air passages; syn- 
cope, from severe shock or alarm; and injury to the head or 
the spinal cord. As regards the last mentioned cause of 
sudden death, it must be remembered that as the phrenic 
nerve arises from the third, fourth and fifth cervical nerves, 
so any severe injury to the cord above the origin of the third 
nerve will produce instant death, by suddenly paralyzing the 
diaphragm and intercostal muscles; while if the injury occurs 
below the sixth vertebra the patient may live some hours, if 
not days, although the action of the greater number of the 
intercostal muscles must be wholly or partially arrested. " 
' "Death as it occurs in disease is usually complicated; but 
in all cases, whether it take place suddenly or gradually, or 
whatever may be the malady, it approaches through one of 
the three vital organs — the brain, the heart or the lungs. 
Life beirg inseparably connected with the circulation of 
arterial blood, death takes place directly the action of the 
heart is completely arrested; and since the action of the heart 
is dependent upon the more or less perfect condition of all 
the vital organs, which stand in a peculiar reciprocal rela- 
tion to each other, a cessation of the functions of either of the 
three speedily arrests the remaining two. Thus innervation 
of the muscles of respiration depends upon the medulla ob- 
longata, the energy of the medulla oblongata upon the decar- 
bonization of the blood, and the decarbonization of the blood 
upon the circulation and respiration. The force of the heart, 
if not directly, is indirectly connected with the medulla 
oblongata, because the circulation of the venous blood destroys 
the irrat ability of the muscles. And so it results that failure 
in any one of the three links in the chain is fatal. Hence 



HINTS TO MEDICAL EXAMINERS. 45 

Bichat spoke correctly of death beginning at the head, at the 
heart, and at the lungs. 

a We may have then— 1st, Death by Syncope, that, form which 
is caused by a want of the due supply of blood to the heart. 
The deaths from flooding after labor, from the bursting of 
aneurisms, &c, are good examples of this form; on examining 
the heart afterwards, the cavities are found empty, or nearly 
so, and contracted. .2d, Death by Asthenia, in which there is 
no deficiency of the proper stimulus of the heart's action — 
the blood — but a total failure of the contractile power of this 
organ. The effects of certain poisons — as hydrocyanic acid, 
of strong mental emotion, of lightning, a blow on the pit of 
the stomach, or the head, &c, — furnish good illustrations of 
this form. Fatty degeneration and organic disease of the 
circulatory apparatus in the chest are other causes." 

DIMENSIONS OF WHITE MEN. 

COMPARATIVE TABLES. 

The United States Sanitary Commission published, in 1869, 
an interesting volume, entitled "Investigations in the Mili- 
tary and Anthropological Statistics of American Soldiers." 

The work contains numerous tables giving the measure- 
ment of soldiers in a variety of ways. Among the mass of 
tables are some which exhibit the average weight and chest 
circumference of many thousand white volunteers and drafted 
men, classified as to nativity and height. For want of space 
to devote to tables of the different statures, a selection has 
been made of such men as were 5 feet 7 inches in height as 
comprising the most numerous class, and all the men included 
in the table were natives of the United States. This Table 
may prove of interest as a means of further showing that the 



46 HISXS TO MEDICAL EXAMINERS. 

adult male of American birth is not so inferior to the Euro- 

geon of New York city, (see page 24.) 
TaUeSko^tneA^eWeivManaaestMeasur 
Native American Soldiers, (White.) 




NATIVITY. 



Average . 
Comput'd Height, 
from 



Weight. 



~1^ 5ft7ta. 140 - 59 
men 



After 
Expira'n 



Full 

Iuspira 1 n 



The New England 
States, 

Ne w York, New Jer- 3177 5ft# 7i n l 141.08 
sey and Penn'a, joaen. I 



34.00 



34.33 



Ohio and Indiana, 



Michigan, Wiscon- 
sin and Illinois, 



1443 
men. 

~945~ 
men. 



5 ft. 7 in. 141.76 34.98 



5 ft. 7 in. H1.33 34.94 




The average dimensions of chest, and also the averag 
I of the men from the New England States, it wi 1 be 
W eight of he men 1 rf ^ of ^ 

observed, is somewha ^s ^ ^ ^ ^ 

ot]l er States menUone^ Verm ^ ^ ^ 

sMre would no £"^ j^ by New York , N ew Jersey, 
haps go beyond the figures • ^ by ^ 

t* j ;c„ „i! i ».. •«■*» i» «. «* 

selves. Marge nam Massachusetts and 

of the New England » gize rf chegt 

Connecticut, and, as a class, less in w g 
for the same height. The average for the New g 
States is in consequence smaller. 



HINTS TO MEDICAL EXAMINERS. 47 

HEIGHT TO WEIGHT AND MEASUREMENT OF CHEST. 



Height. 


Weight. 


Chest. 


Height. 


Weight. 


Chest. 


5 ft. 1 inch 
5 " 2 " 
5 " 3 " 
5 " 4 " 
5 " 5 " 
5 " 6 " 


120 lbs. 
125 " 
130 " 
135 " 
140 " 
143 " 


34.06 in. 
35.13 " 
3570 " 
36 26 " 
36.83 " 
37.50 " 


5 ft. 7 inch. 
5 " 8 " 
5 " 9 " 
5 " 10 " 

5 " 11 " 

6 " " 


145 lbs. 
148 " 
155 " 
160 " 
165 " 
170 " 


38.16 in. 
38.53 " 
39.10 " 
39.66 " 
40.23 " 
40 80 " 



The English Table, (above,) of Weights and Measures is 
again introduced for the purpose of comparison with that of 
American Soldiers, and also for comparison with the table 
below presented. 



HEIG] 


IT. 


AVEEAGE 
WEIGHT. 


AVERAGE CHEST MEASURE. 




Not Inflated. 


Full Inflation. 


5 feet 1 


inch. 


122.33 Hbs. 


31.91 in. 


33.23 in. 


5 " 2 


u 


127.03 " 


32.21 " 


34.85 " 


5 » 3 


« 


131.54 « 


33.00 « 


35.52 « 


5 " 4 


IL 


135.62 « 


33.44 " 


35.85 » 


5 " 5 


U 


139.71 " 


33.94 « 


36.40 " 


5 " 6 


a 


140.84 » 


34.00 " 


36.74 « 


5 " 7 


u 


142.68 " 


34.54 « 


37.00 " 


5 " 8 


a 


148.00 " 


34.67 « 


37.49 » 


5 « 9 


Li 


150.12 " 


35.11 " 


38.00 « 


5 « 10 


u 


155.27 « 


35.64 " 


38.94 « 


5 " 11 


a 


160.70 « 


36.00 « 


39.00 « 


6 « 00 


C'f 


167.21 « 


36.78 " 


39.87 " 



This Table has been prepared with much care and labor, 
from the Weights and Measures of a large number of adult 
male applicants registered in the office of this Company, and 
shows the average weight and average chest measure during 
the acts of expiration and inspiration. The larger part of 



48 HINTS TO MEDICAL EXAMINERS. 

the applicants are natives of this country, and the figures 
were taken from the books without attempt at selection. 

On comparing the English Table with that constructed by 
this Company, it will be noticed that while the weights aver- 
age about the same, there is a larger chest capacity for the 
English Table. It is probable that the measurements and 
weights for the foreign table were taken from men selected 
for their good physical development, rather than from the 
general mass of the adult male population, or, that more 
ca:e wa3 practiced in ascertaining the greatest possible 
degre: of chest inflation. 



FEMALE APPLICANTS. 



&% PPLICATIONS upon the lives of females require an 
fg5| extra blank, to be filled out by the Examiner, and 
which should accompany the application when forwarded. 
The Company does not accept persons under the age of 14, 
and females at that age, or older, must have menstruated and 
the menses regularly established before insurance can be 
effected. 

Some companies decline all female applicants for insurance 
on account of the mortality incident to parturition, particu- 
larly with primiparse and the danger incurred at the climac- 
teric period. Child bearing, and its attendant complications, 
largely increase the mortality previous to the age of 50. At 
or beyond this age, cancerous diseases of the breast, uterus, 
and its appendages, are frequently developed. The Exam- 
iner should use great caution in examining and recommend- 
ing female applicants, and especially those who have attained 
the age of 40 and upward. Ascertain whether the functions 
of the uterine system are normal and regular. The recur- 
rence of puerperal eclampsia, or mania, as well as miscarriage, 
or abortion, precludes insurance, unless the female has passed 
the critical period, (change of life,) and is in good health. 

More or less difficulty is experienced in making thorough 
examinations of females and ascertaining positively regard- 
ing their true condition. Very few would permit a digital 
exploration in cases of suspected uterine disease. The state- 
ment of the applicant concerning the existence and extent 
4 



50 



HINTS TO MEDICAL EXAMINERS. 



of diseases, is in the majority of instances totally unreliable, 
consequently, if the Examiner suspects the existence of pro- 
lapsus uteri, leucorrhoea or any other diseased condition tend- 
ing to induce enervation, the risk should at once be declined. 
The same difficulties also exist with regard to chest measur- 
ment, the corsets and cotton padding so commonly worn 
rendering it impossible to correctly ascertain the size and 
expansion of the chest, as well as preventing an examina- 
tion of the heart and lungs by percussion and auscultation. 
The proper method in such cases is to have the padding and 
corsets removed and the examination made over a light 
wrapper or other garment. No false delicacy should ever 
prevent the Examiner from instituting the most searching 
investigation if any suspicion exists in his mind, and the 
case should be rejected if the necessary examination be re- 
fused. An ansemic or chlorotic condition, also indications of 
the cancerous cachexia exclude of course. In all cases of preg- 
nancy defer the examination until at least two months after 
confinement and the recovery is complete. The pulse of the 
adult female should range from 75 to 80, or five beats per 
minute more than that of the adult male. Married females, 
more especially those who have become mothers, are much 
more desirable as insurance risks than the unmarried, par- 
ticularly unmarried women past the age of thirty years. 

The following table, by M. Odier, exhibits the relative 
longevity of married and unmarried females. 



At the Age of 


A. Married Femah 
has to live 


in Unmarried Fe- 
male has to live 


Difference. 


20 Years, . . . 


40 yrs. 4 mos. 


30 yrs. 8 mos. 


9 yrs. 8 mos. 


25 " ... 


36 " " 


30 " 6 " 


5 " 6 " 


30 " ... 


32 " 5 « 


28 " 11 « 


3 " 6 " 


35 « . . . 


28 " 11 " 


26 " 4 " 


2 " 7 " 


40 « , > . 


25 « 7 « 


23 " 5 « 


2 " 2 " 



HINTS TO MEDICAL EXAMINERS. 



51 



An explanation of the table of M. Odier is made by Dr. 
Milne, in his work on Annuities, which is here quoted. "It 
is obvious that the best organized and most vigorous indi- 
viduals of both sexes, but especially females, are the most 
likely to marry; and that but a small proportion will be 
married of those (particularly females,) who labor under 
any infirmity that tends materially to shorten life. The 
married, therefore, will, upon an average, be a selection of 
such lives from the general mass of the population as ivould 
have been the best, whether they had married or not; and it is 
very difficult to determine what effect marriage may have had 
in improving them." 

The comparative mortality of first and subsequent labors 
is illustrated by the following exhibit. 



Authority. 



Hardy & McClintock 
Mathews Duncan, . . 
Johnson & Sinclair, . 



No. of 
Primi- 



para?. 



No. of 
Deaths 



2,125 
3,722 
4,535 



35 
50 

83 



Or one 

in 
every 



60 
74 
54 



No. of 
Multi- 
parse. 



4,510 

12,671 

9,213 



No. of 
Deaths 



30 

103 

80 



Or. one 



every 



150 
123 
115 



Totals, |10,382 168 



62 



26,394 



213 



124 



Table showing the Mortality from Puerperal Fever in different 
Pregnancies. — Mathews Duncan. 



No. of Pregnancy. 


No. of 
Mothers. 


No. of 
Deaths. 


Per cent, 
of Death. 


Or one 
in 


First, 


2,253 
4,031 
1,563 

189 


97 

85 

47 

9 


4.30 

2.11 
3.01 
4.76 


23 


Second to Fourth, .... 

Fifth to Ninth, 

Tenth to Nineteenth, . . . 


47 

S3 - 
21 



CAUSES FOE REJECTION. 



J^j^HE Home Office reserves the right to reject any or all 
%g§|9 applications presented, and in no instance are the 
Examiners of this Company to construe the rejection of risks, 
recommended by them, as in the least reflecting upon their 
judgment, capacity, or honesty, professionally or otherwise. 

1. Where both parents have died of phthisis pulmonalis 
the risk should invariably be declined. 

2. Where one parent has died of consumption, and it has 
also appeared in brother or sister of the applicant, unless 
the applicant exhibits a sound and healthy condition and 
possesses a good physical development, and has already 
attained the age of thirty-five years. 

3. Where the party has been or is affected with paralysis, 
apoplexy, epilepsy, hereditary insanity, loss of sense and 
voluntary motion, or symptoms denoting softening of the 
brain, shuffling gait, and rapid tendency to obesity or ema- 
ciation, complete deafness or blindness, also cataract, (unless 
removed by operation.) 

4. Intermissions or irregularities in the action of the pulse 
or heart, abnormal sounds or symptoms of hypertrophy, dila- 
tation, or valvular lesions, aneurisms, ossification of the blood 



HINTS TO MEDICAL EXAMINERS. 



53 



vessels, habitual cough, difficulty of breathing from asthma 
or any other cause, haemoptysis, dropsy and bronchitis. 

5. If the pulse is above 88 after due rest and repeated 
trials, and where the pulse is below 58, sitting, unless ex- 
plained by idiosyncrasy or personal peculiarity. 

6. All diseases of the digestive organs materially affecting 
the applicant's health, open ulcers, obstinate cutaneous affec- 
tions, psoas or lumbar abscess, coxarius morbus, unless a long 
period has elapsed since recovery, scrofula, frequent attacks 
of erysipelas and colic, extensive varicose veins, chronic 
enlarged or indurated lymphatic glands, fistulse in ano or 
perineo, irreducible hernia, double hernia, gout, metastatic 
rheumatism, syphilitic rheumatism, and where applicant is 
subject to attacks of inflammatory rheumatism, pneumotho- 
rax and emphysema. 

7. Destructive diseases of the bones, necrosis, disease of the 
spine or joints, spinal curvature, chronic nephralgia, nephri- 
tis, Bright's disease, gravel, calculi, chronic cystis, permanent 
stricture, diabates, enlarged prostate where it affects free 
discharge of urine, Addison's disease, secondary and tertiary 
syphilis, also amputations at the shoulder joint or above the 
knee. 

8. All cancerous or malignant diseases, even when doubt- 
ful or suspicious, including those of the stomach, intestinal 
canal and rectum, tumors, carbuncle, chronic diarrhoea, 
delirium tremens. 

9. In cases where puerperal fever or mania has recurred, 
the risk must be declined, unless the applicant has safely 
passed the climacteric period. Vesico-veginal or rectal fistuhe 
or laceration, phlegmasia dolens, prolapsus uteri, leucorrhcea, 



54 



HINTS TO MEDICAL EXAMINERS. 



(if excessive,) emaciation and exhaustion from lactation. 
Also pregnancy. While any of these conditions are present 
the risk must be. declined. 

"10. In all cases where, in the opinion of the Examiner, the 
risk is not a desirable one for the Company to insure, or 
in cases where the physician has reason to suspect the truth- 
fulness or honesty of the applicant, and where he has a well 
founded doubt whether the applicant will reach his expec- 
tation of life, it is his duty to decline the risk. 

11. Decline all applicants who have had three severe 
attacks of pneumonia. Such individuals not infrequently 
succumb to phthisis. 



HEALTH AND LIFE, 

AS 

INFLUENCED IN THE UNITED STATES BY CLIMATOLOGICAL 

AND TOPOGRAPHICAL CONDITIONS.* 



jnf^ELE following statistics, illustrating the relative salu- 
$tH^ brity of the different sections of the United States, 
are derived chiefly from the Eighth Census Report, to which 
also its terminology and classification of diseases are mainly 
conformed. 

While the returns from every section are defective, they 
are acknowledged to afford a tolerably fair statement of 
comparative mortality, and especially of^the ratio of deaths 
from particular diseases. 

The two tables that I present, afford a summary view of 
the relative salubrity of different sections; and the explana 
tions appended are sufficient for a full understanding. The 
only territorial divisions common to the two tables are the 
High Interior and the Pacific. 

The reader should remember that a comparison, extending 
through a considerable number of years, is necessary to 
obtaining exact results. But, though another census may 
change considerably the ratios of individual States, it can 

* "This article is kindly contributed by Prof. H. P. Gatchell, 
M. D., of Oak Grove Sanitarium, near Kenoslia, Wis. 



56 



HINTS TO MEDICAL EXAMINERS. 



not greatly modify the results for large sections, unless for 
those composed of new States and Territories; the rate of 
mortality being, in general, less in new and sparsely peopled 
than in old and densely peopled States, presenting similar 
climatological and topographical conditions. The mortality 
is usually much greater in cities than in the country. The 
greatest mortality occurs at the extremes of life, especially 
at its commencement. 

Excessive heat is more fatal to the white race than exces- 
sive cold, at least within the limits of the temperate zone. 
Humidity of atmosphere aggravates the effects of both heat 
and cold. The most humid regions are those in the vicinity 
of the Gulf, of the two oceans and of the lakes, particularly 
the southern and eastern shores of the latter. The driest 
region is the high interior. 

TABLE FIRST. 

Ratio of Mortality to every Ten Thousand People. 



LOCALITIES. 


18G0. 


1850. 


Average 


Lower Mississippi Valley, . 


181 


238 


2041 


Atlantic Lowlands, 


134 


145 


139* 


intermediate Region, . . 


132 


119 


125J 


High Interior, .... 


126 


192 


159 


Extreme Northeast, .... 


124 


125 


124i 


Alleghany Region, .... 


108 


96 


102 


Extreme Northwest, .... 


98 


101 


991 


Pacific Coast, ..... 


95 


92 


931 



EXPLANATION. 



The Lower Mississippi Valley comprises Louisiana and a 
breadth of two counties along each bank of the river, as far 
North as Cape Girardeau, in Missouri. ^ 



HINTS TO MEDICAL EXAMINERS. 57 

The Atlantic Lowlands comprise a general breadth of two 
counties along the coast, from Delaware to Florida, inclusive. 

The Intermediate Region comprises the country extending 
from the Alleghanies to the Lowlands of the Atlantic on the 
East, and to those of the Mississippi on the West. 

The High Interior comprises New Mexico and Utah. 

The Extreme Northeast comprises Maine, New Hampshire 
and Vermont. 

The Alleghany Region extends from Pennsylvania through 
Virginia, East Tennessee, &c, to North Alabama. 

The Extreme Northwest comprises Wisconsin, Iowa and 
Minnesota. 

The Pacific Coast comprises California, Oregon and Wash- 
ington. 

The Lower Mississippi Valley, with its alluvial soil, great 
heat and moisture, will always present a large ratio of mor- 
tality. The influence of these causes is not limited to the 
immediate vicinity of the river, but extends throughout the 
neighboring States. While the mortality from consumption 
is small, that from fevers and inflammations is so large as 
to render it very unfavorable to health and life. 

The Atlantic Lowlands consist of alluvial valleys, swamps 
and pine barrens, the latter being characterized by salubrity; 
but there is a sufficiency of the two former to generate a 
large ratio of febrile and inflammatory diseases, notwith- 
standing that the heat is tempered by the neighborhood of 
the ocean. It is due in part, perhaps, to the influence of the 
ocean that the mortality is much les3 than that of the Missis- 



58 HINTS TO MEDICAL EXAMINERS. 

sippi Valley in corresponding latitudes. As in that region, 
so in this, consumption is but little prevalent. 

The Intermediate Region, in general productive and salu- 
brious, is not so much characterized by marked exemption 
from or liability to any particular diseases, as by a moderate 
liability to all. There is, however, a larger ratio of bron- 
chitis, scrofula and diseases of the bones than in most other 
sections of ihe country. The climate is very variable. 

The High Interior is, in all probability, a decidedly salu- 
brious region. The ratio of mortality is considerably in- 
creased by the great number of deaths from violence in New 
Mexico, where the majority of the population existed at the 
Census of 1860. It is not so much characterized by the 
prevalence of any particular diseases as by its marked 
exemption from consumption. The climate is subject to great 
extremes. It is not uncommon for the mercury to fall 40° 
or 50° between noon and midnight. But the singular dry- 
ness of the air causes this great fluctuation to be felt much 
less than in lower and more humid regions. 

The Extreme Northeast probably furnishes more full re- 
turns than most other sections, and thus increases unduly 
the comparative ratio of mortality. Its liability to fevers 
and inflammations is but moderate, but the mortality from 
consumption exceeds that of any other section. The climate 
is rigorous but invigorating. 

The Alleghany Region has always been noted for its salu- 
brity. The country lying on the Western slope of the Alle- 
ganies, and between them and the Blue Ridge, is unsurpassed 
if not unequaled, in this respect, by any other long settled 
portion of the United States. And this salubrity increases, 
according to the Census of 1850, from the Pennsylvania line 



Mints to medical examiners. 



59 



to the 34th parallel of latitude, in Georgia. There was a 
mortality to the ten thousand of 103 in Middle and Western 
Virginia, of 84 in East Tennessee and Western North Caro- 
lina, and of 69 in Georgia, between its Northern line and 
the 34th parallel. 

It is not characterized by the prevalence of any particular 
diseases, but is most noted for the small ratio of consumption 
in its Southern portion. The deaths from consumption were 
99 in the thousand in Middle and West Virginia, 66 in East 
Tennessee, 33 in Western North Carolina, and 28 in Northern 
Georgia. While the winters are not severe, the summers, 
especially in the Southern portion, are, for the latitude, re- 
markably cool and pleasant. 

The Northwestern States present a very small ratio of 
mortality. This is due, in part, to the fact that they have 
been recently settled by a vigorous people, many of whom 
are in the prime of life; but it is due, also, to the extraordi- 
nary salubrity of the country. Nowhere else in the United 
States, if in the world, is there so healthful a region, includ- 
ing so great an area as the belt between the 42d and 49th 
parallels of latitude, extending from Lake Michigan to the 
Cascade Mountains, if not to the Pacific coast. And yet a 
great contrast exists between the climate of the Eastern and 
Western portion of this belt, the latter being characterized 
by great uniformity of temperature, as the former is by great 
extremes of heat and cold, somewhat tempered in the imme- 
diate vicinity of the lakes. 

The superior salubrity of the Northwest is made conspic- 
uous by a comparison of Wisconsin and Vermont in the 
same latitude. 



1850. 


I860. 


Average. 


97 


93 


95 


102 


108 


105 



60 HINTS tO MEDICAL EXAMINERS. 

Wisconsin, 

Vermont, ...... 

But the difference in salubrity does not fully appear in 
the foregoing statement. Not only is Wisconsin not the most 
salubrious of the Northwestern States as Vermont is of the 
Northeastern, but there is a considerably greater proportion 
of children in the former than in the latter, so that with 
equal salubrity, the ratio of mortality should be greater 
instead of less in Wisconsin than in Vermont. 

In consequence of the dryness of the atmosphere, it has a 
small ratio of consumption for a Northern latitude. 

The Pacific Coast, like the Northwest, presents a very small 
ratio of mortality, due partly, as in the latter region, to the 
vigor which pertains to the recent immigration. The very 
small proportion of children also in California, where the 
great mass of the Pacific population is found, tends still 
further to reduce the ratio of mortality. With the lapse of 
time, it will probably present a larger ratio than the North- 
west, especially as its hot interior valleys, comprising a large 
portion of its habitable area, are exceedingly subject to fevers. 
The ratio of mortality from consumption* also equals and 
probably exceeds that of the corresponding latitudes on the 
Atlantic coast; but it is remark.ably exempt, on the coast, 
from the more active inflammatory diseases of the lungs. 
This is due, no doubt to the singular equableness of the 
temperature of this region. 

* Oregon reports a less ratio than California; but the population 
is too small and too recent to make the returns valuable. The 
probability is that its extremely humid winters will generate not 
a little consumption. 



HINTS TO MEDICAL EXAMINERS. 

TABLE SECOND. 

MOST PREVALENT DISEASES. 



61 



NORTH. 


SCUTE— Continued. 


NORTHEAST. 


Cancer, 


Teething, 


Cancer, 


Apoplexy, 


Worms, 


Consumption. 


Epilepsy, 


Skin, 


Disease of Throat, 


Paralysis. 


Heat. 


Apoplexy, 


Consumption, 




Epilepsy, 


Heart, 


WEST. 


Hydrocephalus, 


Hepatitis, &c., 
Diabetes, 


Tetanus, 
Bronchitis 


Diseases of Brain 
not specified, 


Urinary Organs. 

EAST. 


Pleurisy, 

Pneumonia, 

Quinsy, 


Insanity, 

Cholera Infantum, 
Urinary Organs. 


Cancer, 
Apoplexy, 


Fever, Intermittent. 
" Remittent, 


HOETHWEST. 


Paralysis, 


Gastritis, 


Convulsions, 


Asthma, 


Fever, Puerperal, 


Enteritis, 


Consumption, 




Fever, Puerperal, 


Heart, 


HIGH INTEBIOB. 




Urinary Organs. 


Fevers, 


SOUTHEAST. 


MIDDLE. 


Ervsipelas, 


Fever, Typhoid, 


Bronchitis, 


Childbirth, 


Dropsy, 


Scrofula, 


Violence. 


Asthma, 


Bones and Joints. 


PACIFIC. 


Fever, Puerperal, 


E0UT3. 


Fever, Remittent. 


SOUTHWEST. 


Dropsy, 


Scarlatina, 


Dropsy, 


Tetanus, 


Small Pox, 


Fever, Intermittent. 


Asthma. 


Syphilis. 


" Remittent, 


Bronchitis, 


Fever. Infantile, 


" Yellow, 


Pleurisy, 


Apoplexy, 


Diseases of Brain 


Pneumonia, 


Hydrocephalus, 


not specified, 


Quinsy. 


Diseases of Brain 


Tetanus, 


Fever, In term ittent. 


not specified, 


Pleurisy. 


Remittent, 


Asthma, 


Pneumonia, 


" Yellow, 


Enteritis. 


Quinsy, 


Dyspepsia, 


Childbirth, 


Disease of Throat. 


Gastritis. 


Suicide. 





EXPLANATION. 

Of diseases, some are very much and some are very little 
influenced by climate. I have aimed in this table to present 
those that are in a great degree determined by meteorological 
and topographical conditions, though habits of life have much 
to do with liability to and immunity from most diseases. 



62 



HINTS TO MEDICAL EXAMINERS. 



This is especially true with regard to chronic diseases of the 
nervous system, and in some degree those of the heart; these 
two classes, particularly the former, being greatly increased 
by the vicissitudes of commerce, and by anxiety incident 
to the struggle for subsistence in the more densely peopled 
portions of the country. 

NORTH. 

Diseases of the nervous system, heart, liver and urinary 
organs, together with cancer and consumption, predominate 
in the North. There can be but little if any doubt of the 
climatic origin of the most of these, and that they are due in 
a great measure to the influence of cold, or of cold and moist- 
ure combined. To what extent the chronic diseases of the 
heart, and more particularly of the nervous system, may be 
caused by greater intensity of competition in the more densely 
peopled States, and by the reverses of fortune that attend on 
commerce and manufactures, would require careful study to 
determine; but these causes must be largely operative. The 
ratio of fevers and inflammations is comparatively small in 
the North. 

EAST. 

Comparison of the East with the West exhibits a contrast 
very similar to that between the North and South. It sug- 
gests again the importance of habits of life, as well as of 
climate. As the characteristic diseases are chiefly of a 
chronic character, it also raises the question how much the 
exemption of the West may be due to the greater vigor and 
youthfulness of the immigrant population. 

MIDDLE. 

Though bronchitis prevails more in the warm South than 
in the colder North, yet its predominance i§ found to be in 



HINTS TO MEDICAL EXAMINERS. 63 

the Middle Region, where Northern and Southern climates 
contend for mastery * 

SOUTH. 

The influence of heat is conspicuous in the prevalence of 
fevers and of the inflammatory affections of the respiratory 
and alimentary apparatus. Tetanus is due to irritability of 
the nervous system, induced by heat and moisture. Dropsy 
is probably caused by poverty of blood and by chronic 
hepatic diseases, since diseases of the heart and kidneys are 
less prevalent than at the North. Diseases of the skin, in- 
ducing carbuncles, ulcers, fistula?, &c, are in very great 
excess at the South, being eleven times as numerous at the 
Southeast as in the Northeast, and nearly six times as nu- 
merous in the Southwest as in the Northwest. The ratio of 
deaths from consumption is small, being about fifty in the 
thousand for the Gulf States. 

* It is interesting to notice how a bold assertion comes to be 
repeated and at length to be generally accepted on the strength of 
the repetition. Few persons trouble themselves to inquire into the 
evidence in favor of any generally accepted proposition. 

Through a gross mistake in the confounding of a parasitical 
disease in the hog with scrofula in man, it was assumed by physi- 
cians that scrofula resulted from eating the flesh of the hog. The 
error has disappeared from among intelligent members of the 
profession whence it was derived, but it still lingers among the 
people. It is quite common to hear the prevalence of scrofula in 
the Middle Eegion attributed to the excessive consumption of pork, 
in ignorance of the fact that the disease is no more prevalent in 
the South than in the North, though pork is quite as much eaten in 
the Southern as in the Middle Region. In England and Scotland, 
where comparatively little pork is eaten, scrofula causes more 
deaths by fifty per cent, than in our Southern States. It is proba- 
ble that the eating of fat tends to prevent both scrofula and con- 
sumption. 



64 HINTS TO MEDICAL EXAMINERS. 

WEST. 

The West presents decided analogies with the South, as 
does the East with the North. The similarity between West 
and South is due, probably, to the great summer heat of the 
Mississippi valley. Here, as in the South, a high summer 
temperature is prolific of fevers;* while the sharp vicissitudes 
of autumn and winter acting on systems previously sub- 
jected to great heat, are productive of inflammatory diseases 
of the lungs. Consumption diminishes with increase of tem- 
perature and dryness, the more acute diseases of the lungs, 
as in the South, in part taking its place. 

HIGH INTERIOR. 

The returns of 1850 and 1860 are so discrepant with re- 
gard to this region that we hesitate to trust, or how much 
to trust, either. The Census of 1860 assigns a large ratio of 
fevers to New Mexico, and of diseases of the digestive organs 
to Utah. Traumatic erysipelas characterizes the dry inte- 
rior, generally, as far East as Kansas. But what particu- 
larly distinguishes the High Interior is the small ratio of 
respiratory diseases, and especially of consumption. In re- 
gard to exemption from this latter disease, it is rivaled only 
by the Southern portion of the Alleghany Region, and by 
that it is possibly surpassed. I am of the opinion that with 
an improved condition of the population of this region, it 
will rank among the salubrious sections of the country, 
though its Southern portion will always be more subject to 
fevers and will prove less healthful than the Northern.! 

* The mortality from this class of diseases was, in I860 greater, 
in Kansas than in any other State. 

t Altitude is generally unfavorable in asthmatic cases, if asso- 
ciated with cardiac diseases. 



HINTS TO MEDICAL EXAMINERS. 65 

PACIFIC. 

Our Pacific territory extends through seventeen degrees of 
latitude ; but this implies much less diversity of climate than 
would be supposed. One may set out from Point Conception 
and, traveling North through twenty-five degrees of latitude, 
may maintain the same summer mean, that of 60°, yet on 
moving East three hundred miles, he will find himself in a 
summer of 90°. Traveling East from San Francisco half 
that distance, he will exchange a summer of 60° for one of 
85°. The interior accordingly is very much subject to fevers, 
from which the coast is comparatively exempt, as it is also 
from acute inflammatory diseases. 

The prevalence of consumption is greater than on the 
Atlantic coast in similar latitudes. Scarlatina, small pox 
and syphilis have proved very destructive, and infantile 
fever, (regarded as a kind of typhus,) is unusually fatal. 
Nor is the larger ratio of mortality from diseases of the 
nervous system to be attributed solely to the reverses inci- 
dent to mining. The climate engenders a remarkable irrita- 
bility of the nervous system. People feel as if under the 
influence of some stimulus, and they hurry on until they 
suddenly give way and die. The very small ratio of mor- 
tality on this coast is clue in part to a cause common to newly 
settled regions, the vigorous character of the immigrants 
and in part to the very small number of children, less in Cal- 
ifornia, where the mass of the population was in 1860, than 
anywhere else in the United States. There is no likelihood 
of its small ratio of mortality being maintained. 

NORTHEAST. 

In this region we find those diseases most prevalent which 
characterize the North and the East, and here they are more 
5 



66 HINTS TO MEDICAL EXAMINERS. 

intense. Fevers and acute inflammations are comparatively 
rare, intermittent fever being almost unknown. The climate 
is rigorous and humid. 

NORTHWEST. 
But few diseases characterize this region. Convulsions, (a 
disease chiefly of children,) and puerperal fever are more 
fatal than in any other section. 

SOUTHEAST. 

It is somewhat singular that the warm, humid Southeast 
should, like the dry, hot and cold Northwest, be characterized 
by excessive mortality from puerperal fever. That asthma 
and typhoid fever prevail is not unexpected. 

SOUTHWEST. 

In this exceedingly hot and humid region, the diseases that 
characterize the South and West, manifest themselves in the 
the greatest intensity. It is pre-eminently the home of fevers 
and of highly inflammatory diseases. Here also pleurisy and 
remittent fever rage almost without a parallel. Tetanus and 
inflammation of the brain, too, are very fatal. The mortality 
from consumption, as in the South generally, is small, 

CONCLUSION. 

Influenza, rheumatism,* neuralgia, diarrhoea and dysentery, 

* And yet rheumatism originating in a clamp is generally miti- 
gated by transference to a dry climate. Even a removal from the 
lake side of Chicago to the prairie side, is not without effect. So is 
a difference discoverable between the village of Kenosha and the 
place where I now reside, three-quarters of a mile from the lake 
shore, in regardjuot only to rheumatism, but to neuralgia, pharyn- 
gitis, bronchitis and other diseases affected by damp, chilly air. 
This may be due in part to protection by a sand ridge, 



HINTS TO MEDICAL EXAMINERS. 67 

according to the census of 1860, arc but little influenced by 
climate; though, according to the Census of 1850, there was 
a pretty regular decrease of dysentery from North to South. 

The greatest mortality from diseases of the respiratory 
apparatus occurs in the Winter and Spring, from fevers and 
diseases of the alimentary apparatus, in Summer and the 
early part of Autumn. Diseases of the urinary organs are 
most fatal in the Winter, of the liver in the Spring. More 
infants die in hot, more old people in cold weather. 

The greatest number of old people- 1 ' is found in the North- 
east, though the ratio but little exceeds that of the Middle 
Atlantic States, from Delaware to North Garolina inclusive, 
less, probably, than the excess of little children, in the latter 
region, to the whole population. I am confident that the 
Northwest will yet be found more favorable to long life than 
the Northeast. The large immigration from the Northeast, 
like that of the Northwest, is composed mostly of the young 
and middle aged. 

It should not be inferred that an invalid will improve on 
migrating to a region which is comparatively exempt from 
his particular disease. In some cases, such regions should 
be especially avoided. Sometimes relief may be found in 
sections where the particular disease is equally or even more 
prevalent. There are idiosyncrasies of disease as well as 
of individuals. I expect at no distant day to point these out. 

As previously intimated, it is not to be expected that the 
order of salubrity, as indicated in Table First, will be exactly 
maintained. I will hazard and embody in a table a conjec- 
ture as to relative insalubrity, so far as determined by perma- 
nent conditions. 

* Of our political divisions, New Mexico reports, by far, the'" 
' largest ratio of very old people. 



68 HINTS TO MEDICAL EXAMINERS. 

1. Lower Mississippi Valley. 

2. Atlantic Lowlands. 

3. Intermediate Region and entire Northeast. 

4. Pacific States and High Interior. 

5. Entire Northwest and Alleghany Region. 

That the Lower Mississippi Valley will always prove the 
most insalubrious section of our vast and varied country 
there can be no doubt, any more than that the Atlantic Low- 
lands will rank next. It is impossible to determine whether 
the Intermediate region or the Northeast is the more salu- 
brious; but as the Northeast has a much larger city popula- 
tion, and as it has probably given more full returns, I place 
the Intermediate Region first in the line, to indicate that it 
is likely to prove the less salubrious region of the two. 

It is equally difficult to determine between the Pacific 
States and the High Interior; but as the interior valleys of 
California are very insalubrious, and as the Northern portion 
of the High Interior is very favorable to health, I have placed 
the Pacific States first. 

It is equally difficult to decide between the Northwest and 
the Alleghany Region. But since the latter has been much 
longer settled, and since the habits of the people are less 
favorable to health and life than in the Northwest, I have 
concluded to place the Alleghany Region last, as the most 
salubrious. 



INDEX 



PAGE. 

Applicants, 8 

Asthma, 26 

Aneurism or other Tumors, 32 

Age as Affecting the Vital Capacity, 38 

Average Weight and Chest Measure of American Soldiers, 46 

Average "Weight and Chest Measure of Insured Lives of this 

Company, 47 

Bronchitis, , 26 

Correct Answers, 19 

Chest Mensuration, 23 

Consumption of the Lungs, 28 

Cerebral Apoplexy, 42 

Comparative Mortality of First and Subsequent Labors, 51 

Causes for Rejection, 52 

Duties of the Examiner, 9 

Diseases of the Brain, 33 

Diseases of the Heart, 42 

Death by Syncope, 45 

Death by Asthenia, 45 

Dimensions of White Men, 45 

Examiners and Agents, 7 

Expectation of Life, Table of 10 

Emphysema, 26 

Female Applicants, 49 

Females, Married and Unmarried, v Relative Longevity of 50 

General Remarks, 17 

Height, Weight and Chest Measure, (English,) 24, 47 

Hernia, 40 

Health and Life as Influenced by Climate, etc., 55 



70 



HINTS TO MEDICAL EXAMINERS. 



PAGE. 

Intemperance, 33 

Mons. Lombard's Table of Mortality, 16 

Method of Examination, 21 

Mortality from Puerperal Fever, 51 

Most Prevalent Diseases, Table of. 61 

Occupation, 12 

Organs of Circulation, 30 

Persons Under Medical Treatment, 19 

Previous Rejection, 20 

Predisposition to Disease, 41 

Quetelet's Table, 25 

Ratio of Deaths in England, 11 

Registration Report of Massachusetts, 14 

Rheumatism, 43 

Ratio of Mortality, Table of 56 

Spitting of Blood, 29 

Sphygmography and Thermometry, 39 

Sudden Deaths, 43 

Superficial Examinations, 21 

Temperament, 16 

The Pulse, 22 

The Respiratory Organs, 25 

Table Indicating Pulmonary Diseases, 32 

Table of Specific Gravity of Urine, 35 

The Vital Capacity as Affected by Height, *. 36 

Urinary Organs, 34 

Use of Spirometer, 35 

Weight as Affecting the Vital Capacity, 37 



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